Ranking the Effectiveness of Non-surgical Treatments for Knee OA

    A network meta-analysis article published by the Journal of the American Academy of Orthopaedic Surgeons has ranked the non-steroidal anti-inflammatory drug (NSAID) naproxen as the most effective individual knee osteoarthritis (OA) treatment for improving pain and function, noting that the drug is a relatively safe and low-cost treatment method.

    The study authors analyzed data from multiple trials to compare and rank the relative effectiveness of a variety of non-surgical treatments for knee OA: acetaminophen; ibuprofen; intra-articular (IA) injections of cortisone; platelet-rich plasma (PRP); hyaluronic acid (HA); several NSAIDs, such as naproxen, celecoxib, and diclofenac; and oral and IA placebo. Previous research had supported non-surgical management of knee OA with strength training, low-impact aerobic exercises, NSAIDs, and weight loss in individuals with a body mass index over 25.

    “This is the first comprehensive mixed-comparison analysis comparing best-evidence scientific research and excluding lower quality studies that can bias the outcomes,” said lead author and orthopaedic surgeon David Jevsevar, MD, MBA.

    “Using a statistical ranking technique, we worked to provide evidence regarding which of the most common NSAIDs are most likely to decrease pain and improve function, and we attempted to fill in the gaps in evidence for more inconclusive treatments such as HA, PRP, and corticosteroids.”

    The study authors analyzed 53 randomized controlled trials that examined knee OA treatments for at least 28 days and included a minimum of 30 participants per study group. Knee OA treatments were ranked on a scale of 1 to 5, with 1 being the most effective. Findings of the study included the following:

    • For pain reduction, cortisone injections provided the greatest short-term (4 to 6 weeks) pain relief, followed by ibuprofen, PRP injections, naproxen, and celecoxib.
    • Naproxen ranked the highest for probability for improving function, followed by diclofenac, celecoxib, ibuprofen, and PRP injections.
    • Naproxen was ranked the most effective individual knee OA treatment for improving both pain and function, followed by cortisone injections, PRP injections, ibuprofen, and celecoxib.
    • HA injections did not achieve a rank in the top 5 treatments for pain, function, or combined pain and function. An analysis of 12 articles also found that results with HA are not significantly different from those with IA placebo for treatment of knee OA.

    “Because knee OA has both a high disease burden and high treatment costs, additional prospective studies using similar outcomes, timelines, and measures of clinically important changes are needed,” Dr. Jevsevar said. “While the information in this analysis is helpful to physicians, patients also can benefit from these findings and use it with their doctors to weigh all possible treatment options.”

    Although the use of NSAIDs for arthritic conditions such as knee OA has potential risks, including heart attack and stroke, existing evidence indicates that naproxen has less potential for adverse cardiovascular events.


    Jevsevar DS, Shores PB, Mullen K, Schulte DM, Brown GA, Cummins DS. Mixed treatment comparisons for nonsurgical treatment of knee osteoarthritis: a network meta-analysis. J Am Acad Orthop Surg. 2018 May 1;26(9):325-36.